Appendix B Pre Employment Medical Questionnaire Name Date of Birth Post applied for Place of Work School Contact Name Have you worked for HCC before? Yes No Occupational Health may contact you to request further details. Please answer all of the following questions. YES NO DON’T KNOW 1 Have you been absent from work or education in the last 2 years due to sickness? State total number of days…………… 2 Have you ever left or retired from a job for medical reasons? 3 Have you ever had any illness that may have been caused by or made worse by your work? 4 Do you consider yourself to have a disability? If yes and you feel that you need any adjustments or modifications to do the job for which you have applied, please give details below. 5 Have you seen any doctor in the last 2 years for any kind of health problem? 6 Are you having any treatment or investigations of any kind at the moment? 7 Are you waiting for any treatment or investigation? 8 Do you have any eyesight problems not corrected by glasses? 9 Do you have any hearing problems not corrected with a hearing aid? 10 Do you have any difficulty in standing, bending, lifting or any other movements? If yes, please give details overleaf. 11 Have you ever had any back, shoulder, arm, and wrist or neck pain lasting more than 3 days? If yes, please give details overleaf. 12 Have you ever had any problem with your joints, including pain, swelling or stiffness? If yes, please give details overleaf. 13 Have you ever had any mental illness or psychological problems, including depression, anxiety, schizophrenia or self-harm? If yes, please give details overleaf. 14 Do you have any digestive problems? 15 Have you ever had any drug or alcohol related problems? 16 Have you ever had seizures, epilepsy, blackouts, sudden unexplained dizziness or loss of consciousness? YES NO DON’T KNOW 17 Do you have any allergies including latex? 18 Have you ever had asthma, bronchitis or chest problems? 19 Have you ever had diabetes, thyroid or gland problems? 20 Have you ever had high blood pressure or heart problems? 21 Do you have any other medical conditions? 22 Have you ever had any problems with your feet? Have you had any of the following in the past three months 23 Diarrhoea and vomiting lasting more than 48 hours? 24 Sore throat? 25 Symptoms of food poisoning? 26 Infections of any kind? 27 Skin conditions such as eczema, dermatitis and psoriasis? 28 Have you been overseas in the last six months? if yes, have you any illness relating to your travel? In this section, please give full details to any of the questions that you have answered YES to: Question Number Details I certify that to the best of my knowledge the information on this form is true. I understand that if I should withhold information or mis-state any details, my employment may be terminated by dismissal. Signed Date Please put your completed form in a sealed envelope marked with your name, date of birth, post applied for and establishment where the post is based. Return your envelope to Human Resources. If you are appointed, the envelope will be sent unopened to Occupational Health. If you are not appointed, the envelope will be destroyed. Access to Medical Reports Act 1988 The Occupational Health Service may if necessary, request medical information from your GP or Specialist. The Access to Medical Reports Act 1988 gives you the right to check the accuracy of such a report before it is sent to us. You will be informed if a report has been requested. All medical reports received are held in strict confidence within the Occupational Health Department. Under the Access to Medical Reports Act 1988 you have the right to: 1. Withhold your consent for a report to be obtained by Occupational Health from your GP/Specialist. 2. See any report before it is supplied and for a period of up to six months after it has been supplied. This right is subject to you making arrangements with your GP/Specialist to see the report within 21 days of receiving notification from Occupational health. 3. Ask your GP/Specialist to amend any part of the report you consider to be misleading or inaccurate before it is supplied to Occupational Health. 4. Attach a statement of your own views if the GP/Specialist is unwilling to amend the report. 5. Withhold consent for a report to be supplied to Occupational Health Applicants Name Address Date of Birth Day Time Telephone Number Post Code GP/Specialist’s Address GP/Specialist’s Name Telephone Number Post Code Please read your rights as listed above. Please indicate your choice below by deleting the words marked with an *, which do not apply. Failure to delete your choices or complete any other part of this form may result in delays in you commencing in your new post. I have read and been informed of my rights under the Access to Medical Reports Act 1988. I *agree/ *do not agree to the release of medical information by my doctor/ health advisor and/or specialist to occupational health staff at Hampshire County Council should it be necessary when considering my application for employment I *wish/ *do not wish to exercise my right under the Access to Medical Reports Act 1988 to examine any reports which my doctor/specialist and/or my health advisor provides. Signature of Applicant Date Thank you for completing this form. If you have any queries about this form please contact the manger or Human Resource Officer dealing with the vacancy in the first instance or for further enquiries contact the Occupational Health Service on 023 8062 6600. Data Protection Act 1998 In accordance with the Data Protection Act 1998, the information given on this form will be used for medical assessment purposes only and will not be released to anyone who does not require it for this purpose. Any recommendations made on the basis of this assessment may be forwarded as necessary. The form will be placed on your occupational health file and kept throughout your employment, after which it will be archived.